Usually it’s much easier to destroy than to create, but getting rid of institutions can be difficult. Once something is put in place, and people become used to it, it’s hard for them to even begin to imagine a world without it. It took a hard, decades-long fight to get the eight-hour workday. Child labor laws seem obvious and indispensable today, but they came after generations of kids were sent up chimneys and down mine shafts and into cotton fields. Today we have free public schools all over the country, but we did not always. It took decades of effort by reformers and educators to make universal free public schooling a reality. Someday, perhaps, universal free public college will seem just as natural and permanent.
The National Health Service (NHS) is the pride of Britain. Most respondents in a public poll called it the country’s single greatest achievement—this in the land that gave us Shakespeare, Stonehenge, cheddar cheese, and Pink Floyd’s The Dark Side of The Moon. The NHS provides every U.K. resident, from their birth to their death, with healthcare that is free at the point of use. It is good at what it does: Despite the scare stories about wait times and rationing, it is still often ranked one of the best health systems in the world, beating out Canada, France, Germany, Australia, and (of course) the United States. Efforts to privatize and dismantle it have never succeeded—British people are so protective of the service that even Conservative governments have to lavish praise on the NHS and affirm their dedication to its socialistic founding principles.
Americans may have a hard time understanding just how much easier British people’s lives are thanks to the NHS. If you need to go to the doctor, you register with one, book an appointment, go, get treated, and leave. They do not have to be “in your network.” There are no co-pays, no deductibles. If you lose your job, your healthcare is unaffected. Nor does it make a difference if you move to a different part of the country. You will not be billed for your ambulance ride. You will not be billed for your appointment. You will not be given a $629 band-aid or a $5,000 ice pack or an $18,000 bottle of formula. You will not spend hours on the phone with an insurance company trying to figure out why some parts of your hospital visit were covered and others weren’t. You will feel free—free to think about getting well instead of about how to pay for treatment. As my British colleague Aisling McCrea has written, Americans who love freedom and hate bureaucracy should be clamoring for socialized medicine.
But to appreciate how remarkable the NHS is, it’s also necessary to remember that for most of British history, it didn’t exist. This unique egalitarian institution, which guarantees every person access to a good standard of care, even if they are otherwise destitute, is frequently celebrated as an embodiment of “Britishness” or the national spirit. British society, however, has historically been notable for its distinctly un-equal character. Britain is a land with a vicious and rigid class system, where status is signified by the subtlest of differences. (E.g., do you say “napkin” or “serviette,” “jam” or “preserve,” “sofa” or “settee”?) It is strange, when we think of Dickensian England with its earls and its chimneysweeps, to think that socialized medicine would be fully instituted here before the middle of the next century. The United States, the famous land of “equal opportunity,” doesn’t even guarantee sick infants equal care.
Why, then, does Britain have an NHS? Partly because socialists fought for it, and stubbornly refused to accept the status quo. The so-called father of the NHS, Aneurin Bevan, was a radical and obstinate democratic socialist, who as Minister of Health battled the British Medical Association and was determined to implement a system that satisfied the left’s core principles. It would be free at the point of use, it would be comprehensive in its coverage, and it would be open to all.
Bevan is a singular character in British political history. Born into a Welsh coal mining family, he had five siblings die in childbirth or childhood. The poverty Bevan saw around him in mining country turned him into a lifelong class warrior, and he became infamous for stating openly (on the eve of the NHS’s debut, no less) that he would “hate” the Tories for as long as he lived, and considered them “lower than vermin” for letting so many “first class people” live and die in destitution. Bevan’s dream for the NHS was partly inspired by the Tredegar Medical Aid Society of his Welsh hometown, a subscription medical service whereby inhabitants paid a small regular fee in exchange for free-at-the-point-of-use medical care. It had proved hugely popular locally, and Bevan wanted to see the model expanded nationwide.
Though he was on the radical left of the Labour Party, and ended up on the margins in the years before his death in 1960, Bevan was known as one of the greatest orators Britain had produced, and colleagues found him surprisingly warm, congenial, and pragmatic. Those who fought him over the NHS found that he was willing to do business and understood the need to work within existing political reality. Bevan was no utopian. He wanted a health system that actually worked for the people it served. Thanks in part to his skillful stewardship of the service during its early days, that is exactly the kind of system the country got, and the editor of the British Medical Journal later said Bevan was the “most brilliant Minister of Health this country has ever had.”
But it would be a mistake to attribute too much responsibility to Bevan alone. In fact, by the time he became Minister of Health, much of the political work was already done. Over the course of decades, a consensus had emerged among policy-makers and the general public that there needed to be some kind of overhaul of British medicine. In fact, in some quarters there was even a sense that a kind of national health service was “inevitable” and the only question was what form it would take. Rudolf Klein, in The Politics of the NHS, writes that “the acceptance of the need for a national health service long predates” World War II, and there was a prevailing belief that “the logic of circumstances, rather than the ideology of politicians or the demands of pressure groups” would create a national health service.
Sir Arthur MacNalty, the Chief Medical Officer of the Ministry of Health, had said in 1939 that “it is a revolutionary change, but it is one that must inevitably come, because the voluntary system with all its excellent attributes is unsuited to the modern needs of the whole population.” The famous “Beveridge Report,” issued in 1942 by Liberal economist William Beveridge, had sketched the foundations of the postwar welfare state, which would tackle the “five giants” of “Want… Disease, Ignorance, Squalor and Idleness.” The dense report became an unexpected bestseller, and Britons everywhere were talking about it and overwhelmingly approved of its vision. When the end of the war came, there was a public expectation that the proposals made years earlier would now be acted upon.
In fact, Klein writes that in some ways Bevan’s NHS was modest, but that “the virulent hostility of Bevan’s critics… flattered his achievement and exaggerated the extent to which he broke with the sedimentary consensus that had been built up over the previous years.” Winston Churchill’s government, in 1943, had published a white paper proposing “a comprehensive health service for everybody in the country” and Churchill himself had said that:
“The discoveries of healing science must be the inheritance of all: that is clear. Disease must be attacked whether it occurs in the poorest or the richest man or woman, simply on the ground that it is the enemy: and it must be attacked in the same way that the fire brigade will give its full assistance to the humble cottage as it will give it to the most important mansion… Our policy is to create a national health service, in order to secure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”
These words would place Churchill among the far left of the contemporary U.S. Democratic Party. The idea of treating hospitals like fire departments is actually even more socialistic than current “Medicare For All” plans, which provide a government insurance scheme but do not envision government-provided medical services.
Thus if we ask the question “How do you get an NHS?” and simply answer “Make a socialist your Minister of Health,” we’d be disastrously wrong. Bevan was able to beat the doctors because he had the public, and the “tides of history,” on his side. In a 1942 poll, 88 percent of Britons had agreed with the proposal that “doctors and hospital services should be extended, free of charge, to every person” while only 6 percent had disagreed. Politics precedes policy, meaning that having government officials introduce a specific plan is actually the last step. First you have to convince people that a plan is needed and build the power to carry it out.
Unfortunately, the question “What are the necessary social conditions to allow you to introduce an NHS?” must partly be answered: “A devastating war that creates a sense of comradeship and requires de facto nationalization of the hospitals.” Brian Watkin writes in The National Health Service: The First Phase that “war created the opportunity to think in terms of reconstruction and to capture the imagination of a people face to face with annihilation through gestures and language which at other times might have seemed inflated and rhetorical.”
War also created the basic infrastructure for the service. It “generated confidence that it was actually possible to run a complex web of hospitals and services,” and made it so that a state health service had been “already practically established for the purposes of a national emergency.” Furthermore, there had been some kinds of free medical care before the war; the NHS was building on existing infrastructure.
It still took a political fight. Nearly 90 percent of British Medical Association doctors expressed disapproval of the NHS. A meeting of the BMA unanimously resolved that it was “so grossly at variance with the essential principles of our profession that it should be rejected absolutely by all practitioners.” Doctors who did support the service were often ostracized by their peers, and the Socialist Medical Association represented only a small fraction of practitioners. Bevan had to carefully make compromises to placate the doctors without sacrificing any of the core principles of the service.
When the NHS was set to debut, there was a sense of apprehension in the government. Nobody knew whether the experiment would work. Countless impoverished people had been unable to afford care, and there was fear that as soon as medicine became free, the system would become overwhelmed by the demand, with people using far more services than the system could afford, stretching it beyond capacity, causing substantial cost overruns, and diminishing the ultimate quality of care. Familiar warnings were heard: Socialized medicine would lead to equally shared misery.
The nightmare did not come to pass. A 1962 report found that the fears “so far proved to have been largely unfounded.” While the service was more costly than expected, and Conservative governments soon introduced new user fees, British health care has been impressively efficient. Today, the NHS ranks highly on measures of outcomes, and Britain does not spend an especially high percentage of its GDP on healthcare. While the system is under strain, having been threatened by privatization and the failure to adequately expand its budget, it remains good at what it does, and most of its problems could easily be fixed by a government adequately committed to maintaining the service well.
The founding of the NHS offers some useful lessons for our own time. First, even a country with a rigid and ancient class system can achieve some measure of “socialist” institutions. (We can argue about whether the NHS “is socialism,” but Bevan certainly thought it was, saying “a free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society” and calling it “the greatest Socialist achievement of the Labor government.”) Victorian Britain turned into NHS Britain, a remarkable transformation that should offer encouraging evidence of the possibilities for change in the contemporary United States.
The bad news is: The interests opposed to Medicare For All are far stronger and more entrenched than those that tried to stop the NHS. Britain did not have the kind of giant powerful health insurance lobbying industry we have today, and the fight for single-payer in the U.S. will be far more vicious and difficult than the battle for the NHS is postwar Britain. But we do see that the opposition of the medical establishment is not always an insurmountable political obstacles. The vast majority of doctors opposed the establishment of the NHS. They were defeated, and once it was passed, they grudgingly accepted it, and have made no serious effort to get rid of it.
The first task, however, is to build political consensus. It took years from the first proposal of a national health service to its eventual passage and implementation. Advocates spent those years convincing people that the service was not only necessary, not only possible, but also virtually inevitable. This is the phase we are in here today: We have to show people what needs to be done, and build a strong public mandate for the introduction of a new system. They did it in 1948 Britain, we can do it in the 2020 United States.